Pain Management: An Interdisciplinary Approach, presented on May 12, 2016 by Dr. Khai Nguen with VITAS Healthcare of San Diego.

1. Pain Management:
An Interdisciplinary Approach
Presented by:
Khai Nguyen, MD, MHS, HMDC
Medical Director
VITAS Healthcare
San Diego, CA
Developed by:
Barry M. Kinzbrunner, MD, FACP
Chief Medical Officer
VITAS Healthcare
Miami, FL

2. Pain Management for Patients
Near the End of Life
Primary Reference:
Friedman TC, Kinzbrunner BM, Weinreb NJ, Clark M:
Management of Pain at the End of Life. Chapter 6 in
Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical
Guide. New York: McGraw Hill, 2011, p. 125.

3. Goals
• To understand all aspects of a patient’s pain as a
symptom near the end of life
• To recognize physical, social, emotional and
spiritual components of total pain
• To utilize an interdisciplinary approach to promote
effective pain management and quality of life

4. Objectives
At the end of the presentation participants will be able to:
• List various causes of pain in terminally ill patients with
cancer and non-malignant illnesses
• Understand the different factors involved in “total pain” and
how the interdisciplinary team is necessary to effectively
treat total pain
• Define pain and its various characteristics
• Describe the components necessary to perform a full pain
assessment in both cognitively intact and cognitively
impaired patients

5. Causes of Pain
Cancer: Direct
• Bone metastases
• Tumor mass compression
& edema
Cancer: Abdominal
• Bowel obstruction
• Peritoneal carcinomat.
• Pelvic malignancies
• Pancreatic cancer
Cancer: Neuropathic
• Spinal cord compression
• Plexopathies
– Cervical
– Brachial
– Lumbosacral
– Celiac
• Peripheral neuropathy
• Headache due to inc ICP

6. Causes of Pain (Cont.)
Cancer: ChemoRx
• Oral mucositis
• Peripheral neuropathy
• Osteonecrosis
• Tissue injury due to
extravasation of drug
Cancer: Radiation Rx
• Osteonecrosis
• Myelopathy
• Plexopathies
Cancer: Post-surgical
• Stump and phantom limb
• Post-mastectomy and
“phantom breast”
• Post-thoracotomy
• Post-laparotomy
• Post-radical neck dissec.
Cancer: Procedures
• Bone and marrow bx
• LP and venipuncture
• Imaging procedures

7. Causes of Pain (Cont.)
Cancer: Indirect
• Shingles and post-herpetic neuralgia
• Oral or esophageal infectious mucositis
• Paraneoplastic neuropathy or myelo.
• Hypertrophic pulmonary osteoarthro.
• Medication related constipation or urinary retention

8. Causes of Pain (Cont.)
Non-Cancer Pain
• Arthritis
• Metabolic neuropathies
• Chest pain
• Post-traumatic injury
• Post-stroke pain
– Contractures
– Muscle spasms
• Immobility
• Abdominal pain
• Peripheral vascular disease
• Decubitus ulcers and other skin disorders

9. Causes of Pain (Cont.)
Non-Physical Causes of Pain
• Individual’s basic psychological make-up and
tolerance to pain
• Loss of work
• Physical disability
• Change in social and familial roles and relationships
• Fear of death
• Cultural, ethnic and religious background and issues
• Financial concerns

10. Source: Portenoy R., Practical aspects of pain control in the patientwith
cancer. CA-A Journal for Clinicians.38:332,1988.
Total PAIN
Pain
Neuropathic Mechanisms
Psychosocial
Influences
Somatic or Visceral
Nociceptive
Psychological State & Traits
Loss of Work
Physical Disabilities Fear of Death
Social/Family
Functioning
Financial Concerns
Suffering
The Portenoy Model
Total Pain

11. Factors that Affect the
Pain Threshold
Factors that lower
the pain threshold
• Anxiety
• Depression
• Fear
• Isolation
• Fatigue
• Anger
• Sleeplessness
• Persistent pain
Factors that raise the
pain threshold
• Symptom relief
• Rest
• Sleep
• Diversion
• Empathy
• Sympathy
• Medications: analgesics,
anxiolytics, anti-depressants

12. Barriers To Effective
Pain Management
Professional barriers
• Inadequate pain
assessment
• Excessive state and
federal regulations
• Fear of respiratory
depression with opioids
Patient/family barriers
h Reluctance to report pain
– Not wanting to “give in” to pain
– Fear increasing pain means
disease progression
– Fear doctor will not believe them
or will view them weak, difficult,
or as complainers
h Reluctance to take opioids
• Fear of potential addiction
• Inadequate knowledge base

13. What is PAIN?
A Scientific Definition of Pain
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage
or described in terms of such damage”
Source: International Association
for the Study of Pain,1979.

14. What is PAIN?
“Pain is always subjective. Each individual learns the
application through experiences related to injury in early
life… it is also always unpleasant and therefore an
emotional experience”
Source: International Association
for the Study of Pain,1979.

15. What is PAIN?
An operative definition of pain
“Pain is whatever the patient says it is,
existing when s/he says it does”
McCaffery M: Nursing Managementof the patient
with pain.Philadelphia:JB Lippincott,1986.

16. Acute vs. Chronic Pain (Cont.)
Acute Pain Chronic Pain
Onset Usually sudden Long duration
Characteristics Sharp, localized, may
radiate
Dull, aching,
persistent, diffuse
Signs and
Symptoms
Autonomic response
Hyperactivity
Emotional response
Anxiety, restlessness
Autonomic response
Often absent
Emotional response
Flat, depressed

17. Acute vs. Chronic Pain
Acute Pain Chronic Pain
Goal of therapy Pain relief
Sedation often desirable
Pain prevention
Sedation not
desirable
Timing As needed (prn) Around the clock
Dosing Standardized Individualized
Route Parenteral/oral Oral preferred

18. Nociceptive vs. Neuropathic Pain
Nociceptive Neuropathic
Pathophysiology Nerve stimulation from
tissue injury
Direct nerve injury
Description Dull, aching, cramping,
throbbing, pressure-like
Burning, shooting,
tingling, stabbing, vise-
like, electric shock-like
Examples Somatic: Bone mets
Visceral: Angina
Brachial plexopathy
Diabetic neuropathy
Pharmacological
Therapy
Opioids, NSAIDs Opioids + Adjuvants
Tricyclic antidepr.
Anti-seizure meds

19. Pain Assessment
• Pain history
– Pain treatment history
• Full medical history
– Psychosocial and spiritual history
– Medication history
• Physical examination
– Areas of pain
• Mental status examination

20. Pain Assessment (Cont.)
• Pain classification(s)
• Extent of disease and options for primary therapy
• Related psychosocial dysfunction that is
contributing to the patient’s perception of pain
• Available medical, psychosocial and spiritual
support systems

21. Pain Assessment (Cont.)
• Pain diagnosis(es)
• Therapeutic plan
– Physical pain
• Pharmacologic
• Non-pharmacologic
– Psychosocial pain and suffering
• Psychosocial interventions
• Spiritual interventions

22. “P Q R S T” Characteristics of Pain
• P = Palliative, Provocative
– What make the pain better or worse?
• Q = Quality
– How is the pain described?
• R = Radiation
– Does the pain travel or spread anywhere else?
– If so, where?
• S = Severity
– What is the intensity of the pain? (on 0 -10 scale)
• T = Temporal
– Is the pain constant, or does it come and go?

23. Medical & Psychosocial History
• History of all prior and current medical illnesses including
diagnosis and treatment
• A psychosocial history including:
– The patient’s perception of pain
– The patient’s basic psychological make-up
– Any potential factors that may contribute to “total pain”
such as loss of work, financial concerns, physical
disability, change in social or family roles or relationships,
fear of death, cultural, ethnic and /or religious background

24. Spiritual History
“FICA”
• “F”: Faith or beliefs
– What things do you believe in that give meaning to your life?
• “I”: Importance or influence in one’s life
– What role do your beliefs play in your illness?
• “C”: Community
– How does your faith community support you?
• “A”: Address
– How would like us to address these issues in your care?
Puchalski C, Romer AL. Taking a spiritual history allows clinicians
to understand patients more fully. J Pall Med 3:129,2000.

25. Medication History
• Complete drug history including OTC, prescription,
and recreational drug use
• Drug, strength, route, intervals
• PRN or scheduled
• Duration of therapy
• Allergies (obtain full description)
• Side/adverse effects
• Health food store, self remedies
• Patient’s preferences

26. Pain Intensity Scale
The gold standard for assessing pain is to ask about the
patient’s pain severity using the 0-10 pain severity scale. The
Wong/Baker faces rating scale was originally developed for
pediatric patients. It is also very useful in the elderly patient and
patients with language and reading challenges.
®
Worst
Pain
Possible
No
Pain
Moderate
Pain
0 1 2 3 4 5 6 7 8 9 10

27. Role of Assessment in Patient
Management
Pain Management
Pain
Listen &
Believe
Assess
PQRST
Involve
Enhance Quality
of Life
PQRST
Reassess
Cancer pain managementslide and lecture program,Pain service,Departmentof
NeurologyMemorial Sloan-Kettering Cancer Center,1990.

28. Pain Assessment in
Non-verbal Patients
• Pain assessment in the non-verbal patient may be
challenging but is certainly achievable and important
• Indications of pain in a patient who is unable to speak
or describe their pain may include:
– Moaning, groaning, a gasp or scream when touched
– Crying, restlessness, rigid posture, lack of ability to
concentrate, grimace, increased immobility
– Change in sleep patterns

29. Pain Assessment in Cognitively Impaired
Patients: University of Michigan
FLACC
Item 0 1 2
Face No particular
expression or
smile
Occasional grimace or
frown, withdrawn
disinterested
Frequent to
constant frown,
clenched jaw,
quivering chin
Legs Normal
position or
relaxed
Uneasy, restless, tense Kicking or legs
drawn up
Activity Lying quietly,
normal
position,
moves easily
Squirming, shifting
back and forth, tense
Arched, rigid, or
jerking
Cry No cry
(awake or
asleep)
Moans or whimpers,
occasional complaint
Crying steadily,
screams or sobs,
frequent
complaints
Consolability Content,
relaxed
Reassured by
occasional touching
hugging or talking to,
distractible
Difficult to
console or
comfort

30. Pain Assessment in Advanced
Dementia: Miami VA Hospital
Item 0 1 2
Breathing
independent of
vocalization
Normal Occasional labored
breathing
Short period of
hyperventilation
Noisy labored breathing
Long period of hyper-
ventilation
Cheyne-Stokes respirations
Negative vocalization None Occasional moan or groan
Low-level speech with a
negative or disapproving
quality
Repeated troubled calling out
Loud moaning or groaning
Crying
Facial expression Smiling or
inexpressive
Sad, frightened,
frowning
Facial grimacing
Body language Relaxed Tense, fidgeting,
distressed pacing
Rigid
Fists clenched
Knees pulled up
Pulling or pushing away
Striking out
Consolability No need to
console
Distracted or reassured by
voice or touch.
Unable to console, distract or
reassure